DEVAL L. PATRICK
TIMOTHY P. MURRAY Tel: (617) 727-7750
Fax: (617) 727-9368
ELEANOR SHEA-DELANEY www.mass.gov/elder
SANDRA K. ALBRIGHT
TO: Aging Services Access Points
FROM: Eleanor Shea-Delaney
DATE: June 29, 2009
RE: Consumer Directed Care
This Program Instruction (PI) transmits Elder Affairs guidelines for the operation of
the Consumer Directed Care option within the Home Care Basic Non-Waiver and
ECOP Non-Waiver programs.
Consumer Directed Care (CDC) is a service delivery model within the State Home
Care Program (Home Care, ECOP, and Respite) that empowers elders to exert
greater control over the provision of personal assistance services. Elders who are
eligible for the State Home Care Program will have greater choice and control of
their care by having the option to hire, manage, and dismiss their own workers. By
August 1, 2009, all ASAPs shall offer this service delivery model in the manner
described further in this Program Instruction as part of the State Home Care
Consumer Directed Care is not an individual budgeting program. It is a service
delivery model for personal assistance services s uch as Personal Care, Homemaker,
Supportive Home Care Aide, and Home Health Aide. The service plan is
constructed in a manner similar to that used for consumers who choose tradition al
agency services. In Consumer Directed Care, rather than authorize a number of
hours with an agency, the ASAP authorizes an average number of hours per week
that the consumer may directly pay a worker that s/he has recruited, trained, and
hired. The consumer is not responsible for the cost of other services that may be
required, such as Fiscal Intermediary Services, Home Delivered Meals, or
Occupational Therapy. As the cost of Consumer Directed Care may be lower in
some instances, the ASAP has the flexibi lity at times to authorize more service
hours than is generally the case with agency providers. The ASAP continues to be
responsible for the overall management of program service costs within the limits
imposed by the unit rates for Home Care Basic and the Enhanced Community
Options programs. This responsibility is not transferred to the consumer, but the
consumer must ensure that s/he does not engage the worker for more hours than are
authorized by the ASAP.
ASAPs must adhere to the fol lowing rules in the operation of the Consumer
Directed Care option.
I. Consumer Eligibility
Any elder eligible to receive Home Care services is eligible to receive services
through the Consumer Directed Care model unless the elder is enrolled in the Frail
Elder Home and Community Based Services Waiver. At this time, Waiver
consumers cannot receive their services through the CDC model as the Waiver does
not include consumer direction. MassHealth members not enrolled in the Waiver
may choose Consumer Direct ed Care. The ASAP must perform an assessment to
determine the need for a Surrogate 1 to perform some or all of the Employer of
Record’s responsibilities. In the CDC model, the consumer is the Employer of
Record. The responsibilities of the Employer of Reco rd are akin to those of a
traditional employer and are described in detail below.
The eligibility criteria for Consumer Directed Care are:
1. Financially and clinically eli gible for the Home Care Program, the Enhanced
Community Options Program , or Respite Care;
2. Not enrolled in the Frail Elder Waiver;
3. Either does not require a Surrogate as determined by an assessment or has
appointed a Surrogate.
Continued eligibility is dependent on the above and on compliance with the terms of
Consumer Directed Care agree ments (see required forms).
II. Worker Eligibility
A Surrogate is a family member or personal advocate who may fulfill an aspect of the Employer of Record role and
may act and sign documents on the beh alf of the elder. The Surrogate cannot serve as the paid worker.
The elder may hire any individual as long as the worker is not the elder’s Surrogate.
Pursuant to M.G.L. Chapter 6, §172c, a Criminal Offender Record Information
(CORI) check must be completed on any indivi dual who will provide care,
treatment, education, training, transportation, delivery of meals, instruction,
counseling, supervision, recreation or other services in a home or in a community -
based setting for any elderly person or disabled person. Authoriz ed personnel at the
certified agency (ASAP) will obtain a CORI check on the individual to be hired by
Please note that all decisions regarding the hiring of an employment candidate,
acceptance of a volunteer , or referral of an individual to an elder are within the
jurisdiction of the hiring entity, in this case, the elder consumer.
If a candidate’s CORI contains information that may be considered in making a
hiring decision, an ASAP CORI authorized individual must describe the findings on
the Consumer Directed Care CORI form. This form must be sent to the candidate. If
s/he chooses to do so, the candidate may share this form with the consumer. If the
consumer has questions about the CORI information or the screening process, s/he
may contact the ASAP CORI authorized individual for clarification. The consumer
makes the decision to hire, which shall be documented by her/his signature on the
Consumer Directed Care CORI form. This form must be returned to the ASAP by
the candidate. In turn, the ASAP CORI authorized individual may contact the
consumer to verify the consumer’s decision and to answer any additional questions
the consumer may have.
III. Services Offered
Elders may instruct their workers to perform any personal assistance services,
Home Heath Aide
Other assistance with ADLs/IADLs
Services provided must meet needs identified in the assessment process or otherwise
identified as necessary for the health, welfare, and communi ty independence of the
Please note that caregivers who reside with the consumer may not be reimbursed for
assistance with certain IADLs that benefit the caregiver, such as homemaking, chore,
grocery shopping, or meal preparation. Some IADLs, su ch as laundry in the case of a
consumer with bladder incontinence, may be an exception. The care advisor must
work with the consumer and family to ensure the services reimbursed through
Consumer Directed Care are provided exclusively to and for the benefit of the
IV. Employer of Record Role
The elder consumer will become the Employer of Record and (personally or through
a Surrogate) will be responsible for the following:
1. Recruiting, hiring and training the worker.
2. Establishing the worker’s tasks and work schedule.
3. Supervising the worker as to how specific tasks are to be performed.
4. Completing and submitting all necessary paperwork, including forms to
become the Employer of Record, as well as time sheets and agreements.
5. Evaluating and, if necessar y, discharging the worker.
6. Complying with all other terms of the ASAP -Consumer Agreement,
Employer Responsibilities Agreement, and Employer -Worker Agreement(s).
V. ASAP Role
The ASAP will initially determine the elder’s eligibility for Home Care service s and
provide all necessary information to the elder if s/he expresses interest in CDC.
ASAP responsibilities include:
1. Assessing the elder for State Home Care eligibility and the appropriate Home
Care program, specifically the Home Care or Enhanced Commu nity Options
2. Maintaining a regular visit schedule (in accordance with Home Care or
ECOP guidelines) to reassess the consumer’s eligibility for the program, to
evaluate satisfaction with CDC, and to address issues the elder may have.
3. Facilitating the development of the consumer’s service plan; assisting the
elder in identifying the tasks that will be performed.
4. Determining the number of hours per week of personal assistance services
the ASAP will authorize. The service plan is limited by, but not r estricted to,
the program unit rate (Home Care or ECOP).
5. Ensuring that all required Consumer Directed Care forms are complete.
6. Providing the elder/Surrogate with training and guidance on how to be an
Employer of Record, including identifying and explaining the Employer of
Record forms to be completed, providing education on how to recruit and
hire a worker, and explaining how to give direction to and maintain a good
working relationship with the employee. Such assistance may be provided by
the Care Advisor or by ASAP staff employed as Skills Trainers.
7. Obtaining Criminal Offender Record Information on potential CDC workers
and following the instructions regarding CORI contained in this PI.
8. Helping to arrange for and/or authorizing additional needed services, such as
worker training or an Occupational Therapist (OT) home safety evaluation.
9. Providing the elder with ongoing advice and information regarding elder
rights, safety, and access to Protective Services.
VI. Worker Pay Rates
Workers employed by Home Care Pr ogram and ECOP consumers will be paid
$12.00 per hour. Additional costs, such as employer taxes and workers
compensation, will be calculated by the Fiscal Intermediary (see below). The Fiscal
Intermediary will inform the ASAP of the total hourly cost of th e service.
VII. Fiscal Intermediary Role
All ASAPs will be required to use a Fiscal Intermediary (FI) that has an existing
contract with MassHealth for the PCA program and is operating in good standing.
Elder Affairs will provide a list of FIs that meet thes e criteria. The ASAP will pay
the FI the MassHealth administrative rate for services provided.
No ASAP will be allowed to be an FI for Consumer Directed Care. Any ASAP that
is currently acting as an FI for its CDC consumers will have until August 1, 2009 to
transition to a permitted FI. The Fiscal Intermediary’s responsibilities for the CDC
program are described in the Elder Affairs Non -Homemaker Provider Agreement
Attachment A for Fiscal Intermediary Services.
VIII. Role of the Nurse
The ASAP RN may have a consultative role in Consumer Directed Care and may
create a recommended personal care plan to assist the consumer in identifying
personal care tasks that will be performed. The ASAP RN is not responsible for
directing or supervising the provision of person al care. All CDC consumers are
expected to direct and determine their own care, including the supervision of
workers providing personal care. At the consumer’s request, the ASAP may arrange
for assistance by a registered nurse, occupational therapist, or o ther professional.
IX. Worker Training
As the Employer of Record, the CDC consumer will determine if there is a need for
worker training. If the consumer identifies this need, the ASAP will assist in
arranging for the appropriate training.
X. Consumer Directed Care and the Home and Community Based Services
Consumer Directed Care, as established in the above guidelines, is not an approved
service delivery model under the Frail Elder Home and Community Based Services
Waiver. Therefore, Waiver consu mers (including those in the Community Choices
program) may not receive services through this model.
Elder Affairs may incorporate the Consumer Directed Care model in to the Waiver at
a future date. Until this change occurs, however, the following options should be
explored when a Waiver-eligible elder wishes to direct her/his care:
Refer the elder to the MassHealth PCA program, if appropriate. Under
MassHealth rules, the worker may not be a spouse or legally responsible
individual. Home Care/ECOP services can be provided in addition to PCA
services as long as there is no duplication of tasks or services.
Recommend that the elder’s worker seek employment through one of t he
ASAP’s contracted agencies. Services would therefore be delivered throu gh
the traditional agency model. The worker would have to meet the agency
qualifications for personal care workers, be supervised as required within that
model, and may not be a spouse or legally responsible individual.
Effective Date: August 1, 2009
Contact: If you have any questions about this program instruction, please contact Joe
Quirk, Director of Home and Community Programs at Joe.Quirk@state.ma.us
Required Consumer Directed Care forms:
Employer Tasks Agreement
Consumer Directed Care CORI Form